While a majority of the public, and an increasing number of politicians, support a Medicare-for-All health care system, any serious proposal will face major hurdles due to the lobbying power of insurers, big pharma and other industries that are deeply invested in the status quo, according to a new report by Public Citizen.

Organizations from health care-related industries spent $660 million on at least 3,335 lobbyists in 2017, with more than 75 percent of the lobbyists deployed from the pharmaceuticals/health products, health services/HMOs, and insurance or hospitals/nursing homes industries. As the Medicare-for-All debate continues to heat up, private insurers likely will view single-payer as an existential threat to their businesses. Meanwhile, the pharmaceutical and hospital industries are also likely to resist a system that would hinder their ability to charge far more for their services in the U.S. than elsewhere in the world. As a result, congressional lawmakers must eventually choose whether to side with Americans, or with special interests.

“The lobbying push, including television ads and other scare tactics that the health insurance and pharmaceutical industries will use to protect their ability to keep profiting from our fragmented health care system, will dwarf their attacks on health reform efforts of the past,” said Eagan Kemp, health care policy advocate for Public Citizen. “The upcoming debate will test whether our elected officials are finally ready to stand up for their constituents instead of defending self-interested, parasitic corporations that ply them with campaign contributions as long as they keep the health care spending spigot flowing.”

Pharmaceutical Research & Manufacturers of America, the trade association of the brand-name pharmaceutical industry, was tops among organizations analyzed in lobbying spending in 2017, spending almost $26 million in that year. Among individual companies, Blue Cross Blue Shield spent$24 million on lobbying in 2017, the highest of any health insurer, and second highest among all organizations covered in the report. The American Hospital Association and the American Medical Association both shelled out about $22 million on lobbying in that same year.

The report comes as Medicare-for-All gains steam and popularity among American voters. An August 2018 poll by Reuters and Ipsos found that a majority of Democrats (85 percent) and Republicans (52 percent) support such a policy. Many other polls in recent years have found majority support for single-payer Medicare-for-All.

“Increasingly, the public and our elected officials have started to view single-payer as the best solution to our unjust, inhumane health care system,” said Craig Sandler, program associate with Public Citizen’s Congress Watch division, and author of the report. “Advocates for single-payer should not underestimate industry’s inevitable attempts to deceive the public in order to preserve the status quo.”